Elbow Tendonitis: Symptoms of the 4 Possible Tendonitis Types

Are you eager to learn how to recognize elbow tendonitis? Do you want to know its symptoms? You’re in the right place!

In this article, I summarize the key findings from international scientific literature on the symptoms of the four types of elbow tendonitis.

Happy reading! 🙂

(Any questions? Remarks? Let’s meet in the comments!)

♻️ Last update : February 2024. Written by Albin Guillaud, physical therapist and PhD in public health
👨‍⚖️ Disclaimer : no affiliate links. Complete disclosure in legal notices.

Firstly, what is tendonitis?

Strictly speaking, the term “tendonitis” means “inflammation of a tendon.” In reality, there are no problems with tendons that are exclusively inflammatory.

Common tendon problems are generally non-inflammatory or minimally so, and they are always associated with other abnormalities such as:

• Disorganized structure: A tendon is somewhat like a bundle of well-tensed and aligned cables. If these cables break or knot together, we have a disorganized structure.
• Increased vascular and nervous network: In tendonitis (especially those lasting more than 3 months), we may sometimes observe more blood vessels and small nerves than in a healthy tendon.

For this reason, healthcare professionals prefer to use the term “tendinopathy” when speaking among themselves. This term indicates that there is one or more tendon problems, without reference to inflammation.

However, it should be noted that these same professionals tend to use the term “tendonitis” more often with their patients, probably because it is a common term in everyday language. In this article, I adhere to this usage.

Source: Millar, 2021

Now, what exactly is elbow tendonitis?

There are 4 types of elbow tendonitis:

1️⃣ Lateral epicondylitis (also known as “tennis elbow” or “lateral epicondylalgia“), the most common. It usually involves one or both of the following tendons at the elbow:

• The tendon of the extensor carpi radialis muscle.
• The tendon of the extensor digitorum communis muscle.

2️⃣ Medial epicondylitis (also known as “golfer’s elbow,” “golfer’s tendonitis,” or “epitrochleitis“). It usually involves one or both of the following tendons at the elbow:

• The tendon of the flexor carpi radialis muscle.
• The tendon of the pronator teres muscle.

3️⃣ Distal biceps tendonitis (much rarer than the two previous tendonitis). It involves the tendon of the biceps brachii muscle at the elbow.

4️⃣ Distal triceps tendonitis (even rarer!). It involves the tendon of the triceps brachii muscle at the elbow.

Now let’s see how you can tell if you have one or the other of these tendonitis conditions.

Source: Kheiran, 2021

Recognizing tendonitis: key symptoms

When your doctor questions and examines you in their office, it’s called a clinical examination. It’s the primary method for recognizing any type of tendonitis.

Appearance of tendonitis during clinical examination

What does tendonitis look like during a clinical examination? There are two main symptoms that help recognize tendonitis:

(1) Presence of activity-related pain:

• Rather isolated, in the sense that there are no other symptoms besides pain, for example, a swollen elbow or the presence of a palpable lump. I’ll come back to this later.
• Localized in a typical area; the side of the elbow at the forearm level is a typical area. This is not the case, for example, with pain in the middle of the forearm.
• Activated by specific tests for each area. I detail these different tests for each type of elbow tendonitis further in the article.

(2) A story of overuse of the muscles in the affected area, whether in a professional, sports, or artistic context.

“Activity-related pain“, pain during certain movements or activities, distinguishes itself from “resting pain“, the pain that occurs even when not moving.

Note: after a period of intense activity, for example, a tennis match, tendonitis can transiently cause resting pain.

However, sometimes, to ensure that the pain does not come from another problem, imaging (ultrasound or MRI) may be used.

Appearance of tendonitis on ultrasound or MRI

What does tendonitis look like on ultrasound or MRI?

On ultrasound, compared to the same healthy elbow tendon:

• Thickened tendon.
• Tendon with irregular contours.
• Certain parts of the tendon appear darker than others; these are called hypoechoic areas.
• By activating a specific option on the device, certain red or orange spots may be observed on the tendon (indicating the presence of an increased number of blood vessels).

It should be noted that these observations may be present on only part of the tendon.

On MRI, the following can be observed:

• Thickened tendon with irregular contours (similar to ultrasound);
• Certain parts of the tendon appear whiter than others (high-intensity MRI signals – see image).

Caution: Imaging techniques (ultrasound or MRI) are not necessary for diagnosing tendonitis [Millar, 2021]. They are only used:

• to ensure that the pain is not of another origin; an origin that would require a different tailored management than that of tendonitis.
• in case of severely disabling and persistent tendonitis, to motivate a surgeon to operate on you (see the last part of this article dedicated to the treatment of elbow tendonitis).

What are the specific symptoms for each elbow tendonitis?

As a reminder, the two main general symptoms of tendonitis, regardless of the type, are (see the previous section for more details):

1. the presence of rather isolated pain, localized in a typical area and triggered by various specific tests;
2. a story of overuse of the muscles in the affected area.

In this section, I will present for each type of tendonitis:

• The typically painful area of the elbow.
• The tests used to trigger pain and thus help confirm the diagnosis.
• If applicable, other possible symptoms.

Symptoms of lateral epicondylitis or tennis elbow

For lateral epicondylitis, the typically painful area is on the side of the elbow, in the forearm.

The three most commonly used specific tests to aid in the diagnosis of this tendonitis are:

⚫ Painful palpation: The examiner simply palpates the typically painful area (meaning they touch it by applying moderate pressure). If it’s painful, the test is positive.

⚫ Cozen’s test:

• You are first asked to extend your elbow,
• Then you’re asked to perform wrist extension (if your palm is facing downwards, this means lifting your entire hand towards the sky).
• The examiner uses their hand to resist your wrist extension movement.

If this test reproduces pain in the typically painful area, it is positive.

⚫ Maudsley’s test: Here, the examiner simply asks you to extend your middle finger (if your palm is facing downwards, this means raising the middle finger towards the sky).

If this test triggers pain in the usually painful area, it is positive.

Symptoms of medial epicondylitis, golfer’s elbow

Here, the typically painful area is located on the inner side of the elbow, at the level of the forearm.

The tests used to aid in the diagnosis of this tendonitis are:

⚫ Painful palpation: The examiner simply palpates the typically painful area (meaning they touch it by applying moderate pressure). If it’s painful, the test is positive.

⚫ Resistance test:

• Without moving the elbow, you are asked to rotate your palm as far as possible towards the ground and beyond (this is a movement of maximal forearm pronation).
• You are then asked to flex your wrist, essentially a movement where you “break” the wrist.
• The examiner then uses their own hand to resist your wrist flexion movement.

It’s worth noting that for this tendonitis, slight swelling may be present near the painful area.

Symptoms of distal biceps tendonitis

For this tendonitis, the typically painful area is located at the front of the elbow (“at the front” compared to a standing position, arms hanging by the sides with palms facing forward).

The tests and other symptoms for this tendonitis are:

⚫ Palpation may reveal more tension in the biceps tendon compared to the other arm (the healthy arm).

⚫ Resistance test: supination against resistance exacerbates the pain. (Supination involves trying to turn the palm of the hand towards the sky as much as possible.)

⚫ Pain is typically associated with a loss of strength (due to the pain) to bend the elbow when the palm of the hand is turned upwards (in a seated or standing position).

⚫ There is also a loss of strength in supination.

⚫ Sometimes, fully extending the elbow becomes impossible due to the pain.

Symptoms of distal triceps tendonitis

Here, the typically painful area is located at the back of the elbow, somewhat centered (“at the back” compared to a standing position, arms hanging by the sides with palms facing forward).

The tests and other symptoms for this tendonitis are:

⚫ Pain is experienced when palpating the sensitive area.

⚫ Resistance test: extension (straightening the elbow) against resistance worsens the pain.

Sources: Kheiran, 2021; Filippo, 2022

What not to confuse with elbow pain?

Regardless of the type of elbow tendonitis, there is always activity-related pain that is fairly isolated. The problem is that it is not always easy to judge how isolated the pain really is.

In other words, it is sometimes difficult to be sure that the pain does not come from another issue. The diagnosis of any tendonitis therefore requires carefully ruling out any other possibility.

What are these possibilities? There are:

🔴 What are called “red flags“, meaning problems that require urgent attention such as:

• trauma such as fractures, dislocations, or muscle tears;
• septic arthritis (infection of a joint);
• malignant tumors (cancer).

🟠 Problems that are not emergencies but still require specific management promptly:

• systemic rheumatic diseases (affecting the whole body; for example, rheumatoid arthritis).

⚫ Other issues (which can sometimes accompany tendonitis) such as:

• Partial or complete tendon tears.

• Nerve compressions like compression of the posterior interosseous nerve (radial tunnel syndrome); the latter can mimic or coexist with lateral epicondylitis.
• Cervical radiculopathies (irritation of the nerve roots emerging from the cervical spine can cause pain down to the elbow).
• Synovial fold syndrome.
• Instability of the elbow (traumatic or constitutional origin – in hypermobile individuals, for example).

Good news: if you have been diagnosed with elbow tendonitis, it means that all these problems have been ruled out! (At least theoretically, everyone can make mistakes!)

Sources: Javed, 2015; Kheiran, 2021

How to treat elbow tendonitis?

The question of treating elbow tendonitis would require at least a separate article (coming soon). In the meantime, here’s the most fundamental principle for optimal healing:

STAY ACTIVE

If you need to stop working for a while, engage in daily physical activity. At the very least, let’s say for example 1 to 2 hours of walking (possible in several sessions).

If your tendonitis occurred in a sports context, for example while playing tennis, replace your tennis time with another activity while waiting for recovery.

Example: let’s say you played tennis for 2 hours a week. You could replace it with:

• 30 minutes of tennis with your left hand (if you are right-handed).

• 30 minutes of swimming or any other physical activity in the water.

• 1 hour of cycling, walking, running, elliptical training, weightlifting, etc.

Or any combination of these activities or others! In any case, go easy on the intensity for any new activity introduced.

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If you have questions, comments, or experiences to share, feel free to do so in the comments! 🙂

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📚 SOURCES

Konarski W, Poboży T, Poboży K, Domańska J, Konarska K. Current concepts of natural course and in management of medial epicondylitis: a clinical overview. Orthop Rev (Pavia). 2023 Sep 9;15:84275. doi: 10.52965/001c.84275. PMID: 37701778; PMCID: PMC10495044.

Alberta, Frank G. MD* †; ElAttrache, Neal S. MD‡. Diagnosis and Treatment of Distal Biceps and Anterior Elbow Pain in Throwing Athletes. Sports Medicine and Arthroscopy Review 16(3):p 118-123, September 2008. | DOI: 10.1097/JSA.0b013e3181861ded

Kheiran A, Pandey A, Pandey R. Common tendinopathies around the elbow; what does current evidence say? J Clin Orthop Trauma. 2021 May 21;19:216-223. doi: 10.1016/j.jcot.2021.05.021. PMID: 34150494; PMCID: PMC8190485.

Donaldson CT, Finley ZJ, O’Brien MJ. Lateral Epicondylitis Debridement and Repair Using Knotless Suture Anchor. Arthrosc Tech. 2019 Jul 17;8(7):e775-e779. doi: 10.1016/j.eats.2019.03.016. PMID: 31485406; PMCID: PMC6714886.

📷 Image sources

Savnik A, Jensen B, Nørregaard J, Egund N, Danneskiold-Samsøe B, Bliddal H. Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow. Eur Radiol. 2004 Jun;14(6):964-9. doi: 10.1007/s00330-003-2165-4. Epub 2003 Dec 11. PMID: 14669038.

[1] https://commons.wikimedia.org/wiki/File:Biceps_brachii_muscle06.png

[2] https://commons.wikimedia.org/wiki/File:Elbow_coude.JPG?uselang=fr

[3] https://commons.wikimedia.org/wiki/File:Forearm2standard.jpg